Discrimination Online Complaint Form

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Complainant*

Job Title*

Department*

Email Address*

Supervisor's Name*

Home Address:

Work # ( )

Home # ( )

Cell # ( )

ISSUE(S)

Denial of Selection

Termination

Constructive Discharge

Differential Treatment

Denial of Reasonable Accommodation

Denial of Training

Lay-off

Disciplinary Action

Sexual Harrassment

Denial of Promotion

Denial of Leave

Harrassment

Other (please specify)

ALLEGATION(S) BASED ON:

Age (40 and over)

Sex/Gender

Pregnancy

Request for Pregnancy Disability Leave

Retaliation for Protesting Discrimination

Request for Leave for an Employee's Own Serious Health Condition

Marital Status

Religion

Retaliation for Reporting Patient Abuse in Tax Supported Hospitals

Political Beliefs

National Origin/Ancestry (including language use restrictions)

Race/Color

Request for Family Care Leave

Disability (mental and physical, including HIV and AIDS)

Genetic Characteristics and information

Medical Condition (Cancer)

Union Activity

Sexual Orientation

Military or Veteran Status

Gender Identity/Gender Expression

Other (Please specify)

Names and Titles*

Name and title(s) of person(s) causing discrimination and/or harrassment:

Witness(es)*

Name(s), title(s), and contact information of witness(es) or person(s) who may have relevant information or evidence helpful to the investigation and resolution of the complaint:

Circumstances*

Describe in detail the circumstances surrounding your allegations of discrimination and/or harassment. Please include date(s), time(s) and locations where the act(s) occcurred and use a separate sheet of paper if more room is needed and attach to this document.